Cervical cancer awareness

The National Breast and Cervical Cancer Early Detection Program (NBCCEDP), administered by the Centers for Disease Control and Prevention (CDC) through grants to states, tribes, and territories, has successfully provided breast and cervical cancer screening and diagnostic services to low-income women since 1990. (1) Although the authorizing language of the NBCCEDP specifically precludes the use of these funds for treatment, grantees are required to assure that clients have access to affordable treatment services. While grantees have been quite successful in obtaining low-cost or pro bono services, identifying and brokering these services is complex and time consuming. Women's treatment choices may be influenced by cost as much as preference. Awareness of these challenges led to action by advocacy groups, and on October 24, 2000, Congress passed the Breast and Cervical Cancer Prevention and Treatment Act (BCCPTA) authorizing states, if they chose, to provide Medicaid coverage for treatment services for women screened through the NBCCEDP. (2) Researchers from The George Washington University will assess the impact of early access to treatment on the health outcomes and treatment experiences of enrolled women.

Implementing the BCCPTA requires cooperation and coordination among a number of government partners, including the CDC, Centers for Medicare & Medicaid Services (CMS), state Medicaid directors, and directors of state and tribal grant programs. This article outlines the methods used to implement BCCPTA to date and demonstrates the implications for future partnerships among government agencies working toward adoption of public health programs that allow specific populations to gain access to publicly funded health insurance coverage.

METHODS

Implementation of the BCCPTA was coordinated through various communications among CMS, CDC, state Medicaid directors, state screening program directors, service providers, and other stakeholders. These communications ranged from daily telephone and e-mail consultations among CDC and CMS staff members to conference calls, website postings, and a meeting of CDC, CMS, state and tribal screening program directors, and state Medicaid directors in October 2002.

Barriers to the implementation partnership were virtually nonexistent at the federal level, due to constant communication between CDC and CMS personnel. The only major communication barrier experienced during the implementation resulted from the fact that CMS does not typically have routine contact with state Medicaid directors. This provides more opportunities for miscommunications--especially among CMS and state Medicaid directors, and somewhat among state and tribal screening program and Medicaid directors. In efforts to overcome this potential barrier, the stakeholders organized a face-to-face meeting of state and tribal screening program directors, state Medicaid directors, and CDC and CMS staff members to address and help resolve BCCPTA issues and improve communication.

CMS interpretation letter

On January 4, 2001, the CMS issued a letter to state health officials outlining the federal interpretation of BCCPTA. (3) The letter explained that states that wished to choose the BCCPTA option were required to submit an amendment to their existing Medicaid State Plan to CMS for approval. If their plan amendments were approved, states could provide Medicaid coverage for women diagnosed with a breast or cervical cancer or pre-cancerous condition under the state's screening program. If their amendments were not approved, CMS would work with them (i.e., suggesting changes or requesting additional information), and they could resubmit the plan amendment.

Advocate support

As state Medicaid directors evaluated the interpretation letter and considered administrative costs, implementation issues, and appropriations needed for this new provision, the American Cancer Society (ACS) worked with national and local media to communicate the importance of the BCCPTA to the general public. The ACS also met with state Medicaid directors, governors, and state legislators to educate and galvanize support, and worked with state screening program directors to ensure provider participation in the program and to address implementation-related issues. CDC staff members collaborated with ACS and other stakeholders by providing evidence-based cancer information to support public education efforts.

Daily coordination between CDC and CMS

Key staff members from CDC and CMS discussed implementation issues via telephone and e-mail nearly daily. Decisions about issues in question were made based on a mutual understanding of which agency had responsibility to answer the specific question. When issues arose that involved a particular state, conference calls were scheduled to include the CDC and CMS staff members as well as the appropriate state screening program and Medicaid directors.

Conference calls

As states began submitting plan amendments, numerous questions arose from screening program and Medicaid directors regarding the federal interpretation of the Act and the need to collect data related to its implementation. Dialogue between CDC and CMS staff led to the coordination of conference calls tailored to address unique questions from the states. Calls usually involved at a minimum the BCCPTA contact persons for CDC and CMS, state Medicaid and screening program directors (usually to address a question one of them had asked), and the CDC program consultant assigned to work with each screening program. If the question was not resolved during the call, the CDC and CMS contact persons sought higher authorities within their agencies to answer the question, and communicated the resolution to interested parties via e-mail.

One unintended consequence of the interpretation of the Act was confusion among state screening program and Medicaid directors about determining which women would be eligible to receive services under the Act. This confusion often became apparent during conference calls. If a state chose to enroll women under the BCCPTA, the CMS policy stated that eligible women were those screened under the NBCCEDP. In addition, the states could choose to screen women who: (1) "... are screened under a state Breast and Cervical Cancer Early Detection Program in which their particular clinical service was not paid for by CDC Title XV funds, but the service was rendered by a provider and/or an entity funded at least in part by CDC Title XV funds, and the service was within the scope of a grant, sub-grant or contract under that state program ..." and/or (2) "... are screened by any other provider and/or entity and the CDC Title XV grantee has elected to include screening activities by that provider as screening activities pursuant to Title XV." As state screening program directors decided which categories of screened women with positive findings could be referred to Medicaid for treatment, it sometimes became apparent that the screening program's interpretation of appropriate referrals differed from that of the Medicaid directors. For example, some state screening program and Medicaid directors simply did not agree on which categories of women should be referred to Medicaid. One state chose to refer only selected subcategories of women partially funded with CDC funds.

CMS and CDC websites

CMS and CDC both posted information about the BCCPTA on their websites, including a summary of actions, a state activity map illustrating the status of approved state plan amendments, a sample model agreement that could be used as a guide for state Medicaid and screening program directors to designate responsibilities, an opportunity to e-mail questions about the Act, and an extensive list of technical and policy questions and answers developed as a result of the many inquiries received by CDC and CMS. (4-6)

Legislative amendments

When advocates such as the ACS and the National Breast Cancer Coalition recognized that the BCCPTA extended coverage only to eligible women who had no "creditable coverage" as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA), they sought a legislative remedy. Because the HIPAA definition includes a reference to the medical care program of the Indian Health Services, the law effectively excluded Indian women from eligibility for Medicaid under the BCCPTA. Advocates quickly addressed this issue, and on January 15, 2002, the Native American Breast and Cervical Cancer Treatment Technical Amendment Act of 2001 was signed into law. (7) The Technical Amendment establishes eligibility for Medicaid treatment of American Indian and Alaska Native women screened through the federally funded screening programs and found to need treatment. This eligibility applies even if they are also eligible for medical care provided by the Indian Health Services.

Joint CDC/CMS meeting